This review suggests that there is scope for further research in a variety of areas, both personal (in terms of effects on individuals and the development of their coping skills) and social (in terms of understanding why stigmatisation occurs and how it might be reduced).
A number of studies reviewed above indicate that stigmatisation due to derma-tological conditions can have far-reaching and long-term effects on individuals. However, almost all of this work has been cross-sectional. There is always the concern with this type of work that reports of stigmatisation, and their relationship to well-being, might only be due to response biases. That is, people who report low levels of self-esteem and high levels of distress might be vigilant for instances of stigmatisation and more likely to interpret 'neutral' events as instances of rejection. Indeed, Kent (1999) found that instances of enacted stigma were relatively uncommon, with reports of felt stigma being much more frequent. Respondents with vitiligo were much more likely to report that their skin condition affected their lives because of staring and the expectation of stigmatisation than stigmatisation itself. It would be very helpful in this respect to conduct some longitudinal work, perhaps by asking people to keep diaries of their experiences, so that the types of feelings, thoughts and behaviours of affected individuals could be charted more accurately.
Prospective studies could also be conducted. Given that stigmatising experiences seem so important to well-being and adjustment, regular interviews with people who have just begun to show symptoms of skin disease would be most informative. Although difficult to identify (given that most people have their symptoms for some time before seeking professional help, Thompson & Kent, 2001), following such a population would provide much information on the development of anxiety about appearance. In such studies it would be important to monitor feelings of shame and the use of concealment.
Such longitudinal and prospective studies could also provide data about coping strategies - how they are chosen, when they are used and whether they are successful in the short and longer term. Heason (2003) found that people with vitiligo tended to use a combination of problem-solving (e.g. telling others about the condition) and emotion-based (e.g. avoidance) coping strategies, but no information was collected about why and when a particular coping strategy was used. One could hypothesise that people who have experienced stigmatisation are more likely to use avoidance and concealment, a possibility open to testing.
However, it can be argued that the more important areas of research concern the reasons for stigmatisation and how it might be reduced. It would seem more practically useful, and perhaps more ethical given the paucity of resources devoted to helping people with dermatological conditions, to explore ways in which the frequency of stigmatisation can be changed. It may well be that, as Kurzban and Leary (2001) argue, there is a certain amount of hard wiring involved here. Beliefs could be operating out of consciousness and awareness. Reactions to skin diseases will be associated with neuronal activation in the brain. There is some work using functional magnetic resonance imaging (fMRI) to better understand a range of human emotions (Boguslawska et al., 1999), and it may be possible to identify the physiological processes relating to stigmatisation.
To the extent that people are stigmatised due to evolutionary pressures, rejection might be hard to reduce or forestall, especially when the perception of danger is involved. But, because there are cultural differences in the types of conditions that are stigmatised and because what is stigmatised changes over time, there must be a social component as well. Some degree of learning is involved; the question is how learning can be accomplished in a positive direction. Frances' (2004) case studies suggest that people can learn to overcome or reconsider attitudes towards those with disfigurements; the challenge is to explore how such changes can be accomplished on a wider, societal level.
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